3 DAC HHS Alliance Action Plan 3 9/6/2006 Executive Summary In July, 2005, the Doña Ana County Health and Human Services Department (DAC HHSD) and the Doña Ana County Health and Human Services Alliance (the Alliance) hosted the first community health forum in a year-long strategic planning process called Juntos por Cambio. During the next seven months, four additional forums were held. These forums focused on primary care, specialty care, behavioral health, and oral health. Input was gathered from healthcare consumers, providers, public health experts, and political leaders, and many other individuals. This document summarizes the results of the Juntos por Cambio events. It is both a report on the state of health care in Doña Ana County and a call to action for community leaders. The action plan contained in this document offers specific strategies and actions for addressing healthcare priorities in Doña Ana County and building a sustainable healthcare infrastructure. Doña Ana County s healthcare safety-net system is strained by increasing needs and limited resources. The county s location on the United States/Mexico border creates critical health needs linked to environmental, social, inheritable, and economic factors. The county s large rural areas, high poverty rate, and large number of un- and underinsured residents create challenges for health care delivery and access. These challenges must be addressed through the development of sound health policy, financial commitments, recruitment and retention of a stable, skilled, culturally competent healthcare workforce, and ongoing data collection and evaluation. This document provides a comprehensive overview of health issues in Doña Ana County, describes the methods used to collect data, and offers an analysis of the findings. This report concludes with an action plan that provides long-range recommendations and specific actions that can be taken to implement those recommendations, as well as a short-range blueprint for actions to begin in fiscal year In the ever-shifting ecology of community health, multiple effects can be expected whenever one factor is altered or one action is taken. Yet the over-arching goal of this action plan remains consistent: to meet the unmet healthcare needs of Doña Ana County residents, leading to improved health outcomes, increased well-being of residents, and the best possible use of county healthcare resources. The following is a summary of recommendations developed based on data from the Juntos por Cambio forums and workgroups. A full list of action steps needed to carry out these recommendations is found in the Action Plan section of this report: Prevention and Education 1. Increase and coordinate primary and secondary prevention and education efforts 2. Create linkages with existing state and federal resources 3. Increase health outreach through media campaigns 4. Increase use of existing resources

5 DAC HHS Alliance Action Plan 5 9/6/2006 I. Introduction Doña Ana County, like other public entities around the United States, is struggling to meet the healthcare needs of its population. The county is mandated by the New Mexico Indigent Hospital and County Health Care Act to provide care for indigent patients uninsured and underinsured residents of the county and to supplement federal funding for Medicaid. Reliance on these healthcare safety-net services is growing as healthcare costs spiral upward, rates of chronic disease such as diabetes and obesity climb, and private insurance rates decrease not only in Doña Ana County but nationwide. Doña Ana County spent nearly $9 million dollars to fund healthcare safety net services during fiscal year The bulk of those dollars $6.3 million went to hospitals to support indigent care. Two federally-funded healthcare clinics received $1.2 million in supplemental funding from the county, while $1.5 million was spent on ancillary services including ambulance transport, hospice care, behavioral health care, and prevention and health promotion efforts. The county s spending on healthcare was supplemented by state and federal funding, including Medicaid (federal funding matches every county dollar with approximately three dollars), direct provision of services through the state s public health department, and other avenues. The federal government provided $15 million in matching funds to the county s Sole Community Provider Hospitals, Memorial Medical Center (leased by the private for-profit company LifePoint, Inc.) and Mountainview Medical Center, for indigent care. Private foundations also funded health promotion, education, and provision through various grants. All told, the financial investment in meeting the unmet healthcare needs of Doña Ana County residents is tremendous. Is it enough? Are these dollars well spent? As a result of the county s investment, was high-quality healthcare delivered to all eligible residents in the most efficient, cost-effective, coordinated way possible? Did the county s investment improve the health of Doña Ana County residents who rely on safety net service? Will there be enough healthcare resources to meet the county s critical healthcare needs next year? Five years from now? Ten years from now? In an effort to answer these and other questions about the future of healthcare in Doña Ana County, the Doña Ana County Health and Human Services Department (DAC HHSD), at the behest of its advisory committee, the Doña Ana County Health and Human Services Alliance ( the Alliance) and Doña Ana County Commissioner Bill McCamley, implemented a strategic planning process in July of The strategic planning process included a series of community forums and stakeholder work sessions. Input was gathered from healthcare consumers, providers, public health experts, and political leaders, and many other individuals. The process was facilitated by DAC HHSD staff and Dan Reyna, MPH, of the New Mexico Department of Health Office of Border Health.

6 DAC HHS Alliance Action Plan 6 9/6/2006 Forum participants emphasized the need for provision of services today and the need to build a sustainable healthcare infrastructure to ensure that services are there tomorrow. They were keenly aware of the difficult context in which healthcare safety-net services are delivered in Doña Ana County, including the county s lengthy shared border with Mexico, large geographic region, large rural population, and high poverty rate. They recognized that responsibility for health and for health care is shared between citizen, local, state, and federal entities, and private providers. Healthcare resources are limited while the need for healthcare is unlimited and growing a dynamic that affects not only Doña Ana County, but healthcare providers, payers, and consumers worldwide. This document is proof that county residents are acutely aware of the growing gap between resources and demand. By thinking strategically about the future of healthcare in Doña Ana County, county leaders can ensure the best use of available resources and the sustainability of programs. The planning efforts described in this document are both immediate and long-range. Some of the goals can be quickly accomplished through actions described in this plan; some are already underway and the actions outlined here will simply support and enhance those initiatives. Other goals are based on broad visions of systemic change and will not be completed in a few months, a year, or even several years. Along the way, community leaders, healthcare consumers and providers, and all other stakeholders will need to revisit the health status indicators, priorities, goals, and recommendations described in this plan, evaluate the efficacy of actions undertaken, and continue to develop innovative, effective systems to improve health and well-being in Doña Ana County. The steps to systems change outlined in this plan are designed to ensure that healthcare is available to all Doña Ana County residents across their lifespans. When a mother receives prenatal care and gives birth to a healthy child, when that child receive immunizations that protect her from infectious diseases, when the toddler learns to care for her teeth, when she learns how to eat nutritious foods, when as an adult she gives birth to her own healthy children, when as a senior she lives an active life free of chronic disease, one can truly say that healthcare access across a lifespan has made a difference. Systems change does not happen overnight. It happens priority by priority, when people work together and funding and other resources are coordinated. As DAC HHSD Director Silvia Sierra so aptly put it, When we all work together in addressing one thing, we can do systems change. I don t think anybody wants to be sick. Everybody wants to be healthy. For that to happen, they need access to the best healthcare possible for them and their families. This process is not new to Doña Ana County. It s exactly what we did with the Colonias Initiative, and now we can do it with healthcare throughout our county.

7 DAC HHS Alliance Action Plan 7 9/6/2006 II. Background A. Organizational History and Profile Although this plan focuses on the work of one year, it was made possible by many years of planning and collaboration between healthcare providers, consumers, community leaders, and other stakeholders who have worked diligently to improve healthcare in Doña Ana County. The foundation for this project was laid by the Doña Ana County Community Health Council (DACHC) which, in turn, grew out of the Doña Ana County Maternal Child Health Council (DAC MCH). The DAC MCH was created in 1991 when the New Mexico Legislature passed the County Maternal Child Health Plan Act. The act provides funding to New Mexico counties for the development of comprehensive, community-based maternal and child health services. These earlier healthcare planning efforts identified several needs that are echoed in the current plan, including a need to for infrastructure, coordination of services, benchmark data. The theme of scarce resources relative to growing need is not a new one to Doña Ana County. Planning documents that emerged out of those initiatives include the Maternal-Child Health Plan, which is updated annually, and the report Community- Based Planning for Effective, Cost-Efficient Health Care Delivery: Doña Ana County, New Mexico, prepared by Joel A. Diemer and Caroline Willingham, IIRM-CAHE, New Mexico State University. Infrastructure provides the support system within which all healthcare services operate, either individually or collectively. As Diemer and Willingham wrote: Whether specialized or comprehensive, virtually all programs of any consequence require supporting infrastructure. Such support infrastructure is likely to have many dimensions depending on the scope and complexity of the problem(s) being addressed. In terms of scope and complexity, few issues can compare with health care. This is true at almost any scale for which the issue can be considered (29). A major step toward creating that healthcare infrastructure occurred in 2001, when the Doña Ana County Board of Commissioners created the Doña Ana Health and Human Services Department (DAC HHSD) with support from the previous health council. The mission of the DAC HHSD is to improve the quality of life of residents of Doña Ana County by identifying and addressing unmet health and human service needs. When the BOCC created the DAC HHSD, it institutionalized the efforts of the county health council. In addition, it secured permanent resources to address issues identified by the previous health council. The department has grown into a multi-division organization. The department heads up the Colonias Initiative for the entire county, making sure that core infrastructure needs are met for county residents. Department divisions are the Health Care Division, Behavioral Health Division, and the Community Outreach Division.

8 DAC HHS Alliance Action Plan 8 9/6/2006 The Health Care Division administers sole community provider funds for the county s two hospitals, external agency contracts for health car and ancillary service providers, and manages the indigent claims fund for all of Doña Ana County. The Behavioral Health Division focuses on the implementation of behavioral health programming for the county. These services are primarily preventive in nature and focus on the development of life skills for program participants. This division also oversees the Local DWI Grant as well as DOH/BHD grants and Federal SAMHSA Grants. The Community Outreach Division works as a liaison with communities in the county. The Community Outreach Division has developed community coalitions, which are guiding the Colonias Initiative for the county by providing advice for capital outlay requests and implementing projects using previous year's allocations. The division also serves to forward other county department activities through resource fairs and outreach mechanisms for information dissemination through out the county. This division has traditionally been responsible for Maternal Child Health funding as well as the county's AmeriCorps VISTA Program. In January, 2005, the Doña Ana County Board of Commissioners created the Doña Ana County Health and Human Services Alliance (the Alliance). The creation of the Alliance was an important step toward coordination of health-planning efforts in the county, for it brought together all existing county-level health-focused councils and created liaisons with regional health-planning groups. The Commissioners purpose in authorizing the Alliance was to create an advisory body for the DAC HHSD that would improve coordination and collaboration, nurture public understanding, strengthen accountability, promote informed policy-making, and provide an opportunity for effective community input. The Alliance has incorporated the duties of several councils including the Driving While Intoxicated (DWI) council and the Health Council for Doña Ana County. For example, with approval from the New Mexico Department of Finance and Administration, the Alliance serves as the legislatively mandated Local DWI Council. In addition, the Alliance serves as the health council by identifying health needs and resources in Doña Ana County and developing this action plan. The creation of the DAC HHSD and the Alliance represent important steps toward creating a viable healthcare infrastructure to support the work of many dedicated community leaders who devote a tremendous amount of time, expertise, and energy to health planning in Doña Ana County. DAC HHSD staff provides technical and administrative support to the Alliance as part of the department s role in meeting the county s responsibilities for improving the core public health functions of assessment, policy development, and service provision. The Alliance integrates several advisory bodies to create a common sense of purpose and shared understanding of methods and perspectives, while promoting new channels of communication. Alliance membership is not based on representation from specific

9 DAC HHS Alliance Action Plan 9 9/6/2006 organizations. The membership of the Alliance includes representation of key public, private, voluntary and not-for-profit stakeholders and community-based representation to assure fairness, geographic balance, and life-cycle representation. This diverse base of community stakeholders affords a far-reaching perspective beyond that of a limited healthcare vacuum. For the complete Alliance Operating Guidelines, please see Appendix A. The Alliance provides direction to the DAC HHSD, which, in turn, implements programs based on Alliance direction, fiscal responsibilities, and DAC BOCC directives. Thus, Doña Ana County no longer has organizations working in isolation. The DAC HHSD has the support and resources of the DAC BOCC and the validity of a community-based process through the Alliance. This structure brings government resources and community input together to develop, implement, and evaluate this action plan. During its first year, the Alliance developed the community-based strategic planning process that led to this report and action plan. Data for this action plan were gathered during the "Juntos Por Cambio" health forums, which identified needs in primary care, specialized care, behavioral health, and oral health for Doña Ana County. Providers, consumer, and advocates participated in the process. The priorities reflected in this plan were developed during a series of five community and stakeholder forums and subsequent work sessions. A complete description of the planning process is found in the methods section of this document. This plan documents the ability of the Alliance to lead a cooperative, community-based healthcare planning effort and demonstrates the clear benefits of the Alliance/DAC HHSD structure and relationship. This plan, which was made possible by that relationship, represents a major step toward providing the DAC HHSD with a comprehensive profile of the county s health status, leading to more informed-decision making. It provides guidance to the DAC HHSD to maintain effective and efficient methods for using county resources to provide services. Finally, this report uses Healthy Gente 2010 as the framework for measuring the improvements in health status anticipated from the actions described in this plan. Healthy Gente 2010 is a set of indicators of health status for residents on the United States side of the US/Mexico border. These evidence-based benchmarks provide the foundation for developing measurable outcomes and objectives for health status in Doña Ana County, thus increasing the DACHHSD s ability to leverage state and federal program funding and technical assistance. As a result of the establishment of the DAC HHSD and the Alliance as its advisory body, available resources can be coordinated to address the needs, gaps, and priorities identified in this comprehensive healthcare action plan. Successful implementation of this plan will have long-lasting influence on the coordination, monitoring, and evaluation of the health and human service delivery system in Doña Ana County.

10 DAC HHS Alliance Action Plan 10 9/6/2006 B. Living in Doña Ana County Geography, political boundaries, and associated socio-economic factors strongly affect the health status and unmet health needs of Doña Ana County s population. The county includes 3,807 square miles of land in south central New Mexico, bordered on the south by Chihuahua, Mexico and on the east by the Texas. Doña Ana s location on the United States/Mexico border gives it a dual identity as both a county in New Mexico and part of a cluster of border counties. According to United States Census Bureau estimates, the population of Doña Ana County was 186,095 in Of that population, 63.4 percent were of Hispanic or Latino descent, 1.5 percent were Native-American, 1.5 percent African-American, and.8 percent Asian-American. Most of the remaining 35 percent were of Anglo descent. Of the Hispanic population in Doña Ana County, the vast majority are of Mexican descent. If you live in Doña Ana County, you enjoy warm weather, beautiful views, and sunshinefilled days. You live in an area with a rich cultural heritage, a large university, an array of restaurants, desert beauty, and the backdrop of a dramatic mountain range. You probably speak at least a smattering of Spanish, and there s a 54.4 percent chance that Spanish is the language you speak at home. There s a one-in-four chance that you re one of the 24.5 percent of Doña Ana County residents who live below the federal poverty (FPL) line of $15,735 for a family of two adults and one child. The New Mexico poverty rate is 17.7, and the United States rate is 12.5 percent. If you re under 17 and live in Doña Ana County, the probability that you ll live in poverty rises to 35.1 percent, compared to 25.9 percent for the entire state and 17.6 percent for the nation as a whole. The state of New Mexico is the second poorest in the nation, with only Mississippi having a lower median income. The median family income in Doña Ana County in 1999 was $29,808, compared to a statewide median of $34,133 and a nationwide median of $41,994. One in three people in the county don t have health insurance of any sort, and if you work for a small business, there s a good chance that you re one of those people, especially if you re an adult. Your children, however, are more likely than you are to have health insurance. About three in four children are covered, most by Medicaid or the State Children s Health Insurance Plan. You don t have to be unemployed not to have health insurance only 51 percent of businesses in southwestern New Mexico offer health insurance to their employees. If you make less than $30,000 a year, there s a good chance that your employer is one of the other 49 percent. Statewide, only one-third of companies that pay employees less than $30,000 per year offer health insurance options. There s a good chance you never planned to have those children. About 50 percent of pregnancies in Doña Ana County are unintended. Fewer than 7 out of 10 pregnant women of all ages will start receiving prenatal care during their first trimester. That s a

11 DAC HHS Alliance Action Plan 11 9/6/2006 little better than the state proportion of 71 percent, but far below the national rate of 80 percent, and even further below the Healthy People 2010 objective of at least 90 percent. The low rate of prenatal care is partly a result of a high rate of unintended pregnancies. Unintended pregnancies are strongly associated with poorer preconception health, including abuse by a partner, unhealthy maternal lifestyle during pregnancy, including cigarette smoking, use of alcohol and other drugs, and poor nutrition. Birth outcomes if unintended pregnancies include higher rates of premature delivery, low birth-weight, and small size for gestational age. Later in life, these children may experience lower cognitive, behavioral, and emotional development, as well as child abuse and neglect. Your kids, however, are probably immunized against major childhood diseases. Increasing rates of health insurance coverage for children, coupled with a mandatory school entrance immunization requirement passed in the early 1980s and state-sponsored free vaccine programs, have dramatically increased the statewide percentage of children immunized by school age. Childhood immunization rates reached a low in New Mexico of about 63 percent in , but had climbed to their highest level ever about 71 percent by This rate is still well below national rates of 78 percent and the 90 percent needed according to epidemiological studies to eliminate the potential for disease outbreak and achieve appropriate population-level immunity. Current state immunization objectives are to focus on each child receiving a full complement of the 20-plus recommended immunizations by the age of two. Both Healthy People 2010 and Healthy Gente 2010 also identify 90 percent as objectives for the nation and the border area. Even if your children are immunized, there s a good chance that they ll have dental caries (cavities) and possibly periodontal disease by the age of five, and that it will negatively affect their health for the rest of their lives. Those oral diseases increase your kids chances of developing diabetes, heart disease, and possibly even cancer. If you re a female teenager, look around at your peers. Nearly half (48 percent) of you will be pregnant before you reach 17. More than 12 percent chance of you will be physically hurt by a boyfriend over the course of a year, and 8.8 percent of you will be physically forced to have sexual intercourse during that same time period. If you re a male teen, you re susceptible to violence, too, but it s likely to come in the form of fighting half of male teens get in a physical fight over the course of a year. Regardless of gender, too many teens (37.3 percent, compared to a state rate of 34.9 percent) will ride with a drinking driving over the course of a month; 17.5 percent of them, compared with a state rate of 19.1 percent, were themselves the drinking drivers. If you live in one of Doña Ana County s 37 colonias settlements in unincorporated areas that lack access to a sanitary water supply, wastewater treatment processes, and paved roads your health is likely to be poorer than most other residents of the county. Public health advances that have been established since the early 1900s in other parts of the United States, such as wastewater treatment, access to potable water, and immunizations, have not reached the colonias. Both children and adults in these

12 DAC HHS Alliance Action Plan 12 9/6/2006 settlements have increased rates of preventable infectious diseases including tuberculosis, pertussis, and gastrointestinal infections. If you live in Doña Ana County, your life is most likely to end because of heart disease. In 2004, the leading causes of death in Doña Ana County were diseases of the heart, which caused 292 out of 1,206 total deaths in the county. Malignant neoplasms caused 258, unintentional injuries 88, and diabetes mellitus 87 deaths. Diabetes is the fifth leading cause of death in New Mexico, but the fourth (barely) leading cause of death in Doña Ana County. If you have diabetes, there s a good chance that you ll also develop heart disease, so even though your death may be listed as cardiac-related, diabetes may have been the underlying culprit. More than six percent of New Mexicans have diabetes. If you re a Hispanic/Latino American and your ethnic roots are in Mexico, you have twice the chance of developing diabetes as a non-hispanic white, according to the Centers for Disease Control. C. Accessing Health Care in Doña Ana County There are healthcare services available to Doña Ana County residents. You just need to know how to access them. You can sign up for some of the health education programs offered at the county s six community resource centers. If you re savvy or if you ve received assistance from a community health advocate, or promotora you may know that health care isn t out of reach. If your family s income falls below the federal poverty level, you re female and you re pregnant, or if you re a child, you probably qualify for Medicaid. Whether you ll be able to find providers who accept Medicaid is another question. Whether or not you have insurance, you can access primary health care, including some oral health and behavioral health services, through one of two federally qualified health centers (FQHCs) Ben Archer Health Center or La Clinica de Familia. Both FQHCs have clinics in remote areas of the county. You may be able to find health care through other private and public sources. If your income is less than $800 a month and you don t qualify for other services, you can get at least basic primary care and screening at Saint Luke s Health Care Clinic. Two hospitals receive county funding to provide emergency and specialty care, which you can access if you qualify as indigent or if you re eligible for Medicaid or Medicare. Women and children can receive reproductive health services and early childhood care through the First Step program. In fact, so many services are available that you may find yourself confused about when, where, and how you can get health care and how much you ll need to pay. You may not know when and where your children can get immunizations, how to protect yourself from sexually transmitted infections, or that you can transmit cavities to your baby by tasting her food then using the same spoon to feed her. Even if you know that eating a nutritionally balanced diet and exercising regularly are ways to maintain good health, those precautions might be impossible for you to follow if you're a single mother living in Anthony and working two low-wage jobs to make ends meet. Fresh fruits and vegetables might not be easily available to you if you live in a low-income neighborhood.

13 DAC HHS Alliance Action Plan 13 9/6/2006 Despite the wide array of services available, you might fall through one of the many gaps that exist in the healthcare system. You might have private health insurance but a high deductible, leaving you responsible for most of your own healthcare costs. If you re older than 65 and on Medicare, you ll have about 43 percent of your medical expenses covered. The other 57 percent will come out of your own pocket. And Medicare doesn t cover oral health care costs, so if you start having problems with your teeth, your only resource will be the sliding fee scales at one of the FQHCs, where you can get basic dental work done. If you need specialty dental care, well, that s another story. If, like about 50 percent of the county s population, you live in a rural area and want health services, you ll need a reliable vehicle to access those services. While limited public transportation services exist, most serve only the Las Cruces area. Faced with these and other barriers to accessing health care, you may not do anything at all until you have a health crisis. Then you may end up calling an ambulance to transport you to an emergency room. You may have developed a chronic disease diabetes, heart disease, cancer, asthma which probably could have been prevented if you d received some preventive care and education along the way. But at this point, your disease may be so advanced that you require specialty care, surgery, life-time medications, and even assistance with the activities of daily living. After you leave the emergency room, you may get lost again, falling back into the gap until the next time you have a health crisis. D. A Strained Safety-Net Doña Ana County offers a wide range of safety-net services to low-income residents, including prevention and education, primary care, oral health, behavioral health, and specialty care services. Funding for safety net services comes from a complex mixture of federal, state, local, and private foundation funding, as well as individual payers. Yet public funding for health insurance and health care is not keeping up with the demand, including Medicaid and Medicare, community health centers, public health clinics, public health infrastructure, and services for people with special needs. Under the New Mexico Indigent Hospital and County Health Care Act, 30 of New Mexico s 33 counties Doña Ana County among them provide hospital care and ambulance transport for indigent patients and supplement federal funding for Medicaid. The Indigent Hospital and County Health Care Act defines indigent patients as persons who receive healthcare, can normally support themselves and their families, but cannot pay the cost of care. The act designates the individual county as responsible for paying for ambulance transportation, hospital care, and the provision of health care to indigent patients. Counties must provide local revenues to match federal funds for the state Medicaid program, including the provision of matching funds for payments to sole community provider hospitals and the transfer of funds to the county-supported Medicaid fund pursuant to the Statewide Health Care Act. Countywide health planning is also encouraged under the act, as it can improve the provision of health care to indigent patients.

14 DAC HHS Alliance Action Plan 14 9/6/2006 In 2004, counties statewide collected $38.8 million for financing of health care, primarily through gross receipt taxes. All counties spent $41.2 million for safety-net medical services, exceeding revenues by 5.0 percent. In 2003, expenses exceeded revenues by 6.5 percent. The decline was mostly due to an increase in gross receipts taxes. Still, while county revenues increased from $25.49 million in 2000 to $38.8 million in 2004 (a 52.2 percent increase), expenditures on health care financing increased 68.4 percent from $24.17 million in 2000 to $40.7 million in Doña Ana County was one of 16 counties to provide safety-net healthcare services to its residents that exceeded its annual gross receipt revenues. Clearly, such a level of expenditure cannot be sustained. Despite this significant funding, essential health services are still not being provided to many county residents. To ensure that all residents have access to health care and that the county is getting the most bang for its buck the county, like other public entities, must think strategically about healthcare needs now and in the future. The current situation is part of a national picture that has more to do with the way healthcare financing has evolved over the years than with any mismanagement or errors on the part of an individual provider, state, or county. A full discussion of healthcare financing policy is beyond the scope of this report. However, it is important to note that healthcare systems in the United States have evolved to provide an all or nothing type of situation. While some people cannot access care, others receive too much, often unnecessary, and costly care (Bodenheimer 1). Healthcare resources tend to be broken into silos with little communication between providers in different areas. A decline in employer-sponsored health insurance coverage is one of the major stresses on the publicly-funded healthcare system. As fewer and fewer people are covered by traditional employer-sponsored private insurance, many are turning to public sources to help pay for healthcare. According to the Kaiser Commission on Medicaid and the Uninsured, the number of uninsured people in the United States increased by nearly six million between 2000 and During the same period, employer-sponsored insurance dropped from 68.9 percent to 65.1 percent. The majority of growth in uninsured adults has been among those with incomes below federal poverty level (46 percent) or those whose incomes fall between 100 and 199 percent of the federal poverty level (22 percent). People in southern states have been most affected. Minorities and non-citizens, while more likely to be uninsured, do not account for the majority of the grown in the uninsured over these four years. Nationally, four out of five (81 percent) people who are uninsured live in working families. Nearly 70 percent of them live in households with at least one full-time worker, while 13 percent have a part-time worker. People most likely to be uninsured are lowwage workers, those employed in small businesses, service industries, and blue-collar jobs.

15 DAC HHS Alliance Action Plan 15 9/6/2006 Children are as likely as adults to lose employer-sponsored insurance, but because of expanded eligibility for public insurance programs, largely Medicaid and the State Children s Health Insurance Program, children did not lose coverage as dramatically as adults. Children covered by public insurance increased from 17 percent to 22 percent, resulting in a slight decrease in the share of children without coverage. Rates of employer-sponsored insurance in New Mexico are below the national average. In January 2005, the New Mexico Health Policy Commission/NMSU reported that statewide, 59 percent of New Mexico employers provide health insurance to their employees. Rates in the southern part of the state were lower, at 51 percent. The smaller the business, the less likely it was to provide health insurance to its employees (with the exception of the self-employed). Of those who did provide insurance, only 37 percent statewide and 36 percent in the south/southwest paid 100 percent of their employee premiums. For those who provide, fund, and administer safety-net healthcare services, dropping rates of employer-sponsored health insurance present a dual challenge. Not only are the actual numbers of individuals who qualify for publicly-funded health increasing, but their healthcare needs tend to be greater and more costly. The uninsured are less likely to receive preventive care, such as immunizations, screening exams for cancer, diabetes, or heart disease, and routine checkups. When they do access the health system, it is often only after chronic mild illness has become a serious disease or an acute emergency. Even among those whose jobs pay a living wage, a healthcare crisis can negatively and seriously impact financial stability. According to the Kaiser Family Foundation, more than a third of the uninsured have a serious problem paying their medical bills, and nearly a fourth are pursued by collection agencies for medical bills (Kaiser, Why Are So Many Americans Uninsured? 2). In some cases, the healthcare crisis may lead to loss of employment, increasing financial duress and the load on publicly-funded healthcare systems. The following table illustrates barriers to health care access faced by people with and without health insurance.

16 DAC HHS Alliance Action Plan 16 9/6/2006 The decrease in employer-sponsored health insurance can be attributed to many factors, including rising insurance rates, increasing rates of chronic disease, rapidly rising healthcare costs, an entire system that s fraught with inefficiencies, and the need for employers to reduce overhead costs. People with health insurance tend to be healthier, partly because they are more likely to be able to afford to seek health care when and sometimes before they need it. Insured adults in poor health seek care from a physician 70 percent more often than uninsured adults in poor health (Newacheck et al, 1998, qtd in Bodenheimer 20). Insured adults receive 90 percent more hospital services than the uninsured (Hadley et al, 1991 qtd in Bodenheimer 20). E. Why are Some People Healthy and Some People Not? Because health insurance affects the ability to access health care, it is an important influence on health outcomes. Yet lack of access to care is only one reason why the health of Doña Ana County residents is much poorer than the rest of the nation. To build an effective safety-net healthcare system, stakeholders must recognize the other factors that determine health outcomes, called the determinants of health. Traditionally, public health literature has identified the four major determinants of health as socio-environmental factors, bio-physiological factors, individual psychosocial and behavioral factors, and access to healthcare. These determinants interact to create the entire context of a person s life and health status.

17 DAC HHS Alliance Action Plan 17 9/6/2006 The World Health Organization identifies several additional determinants of health, which can be seen as sub-categories of the four major determinants: Income and social status - higher income and social status are linked to better health. The greater the gap between the richest and poorest people, the greater the differences in health. Education low education levels are linked with poor health, more stress and lower self-confidence. Physical environment safe water and clean air, healthy workplaces, safe houses, communities and roads all contribute to good health. Employment and working conditions people in employment are healthier, particularly those who have more control over their working conditions Social support networks greater support from families, friends and communities is linked to better health. Culture - customs and traditions, and the beliefs of the family and community all affect health. Genetics - inheritance plays a part in determining lifespan, healthiness and the likelihood of developing certain illnesses. Personal behavior and coping skills balanced eating, keeping active, smoking, drinking, and how we deal with life s stresses and challenges all affect health. Health services - access and use of services that prevent and treat disease influences health Gender - Men and women suffer from different types of diseases at different ages. (World Health Organization: The Determinants of Health) Because gender, race, ethnicity, education or income, disability, geographic location, and sexual orientation all affect the determinants of health, they can lead to great inequities in the health status of populations. Differences in health status because of gender, race, ethnicity, education or income, disability, geographic location, or sexual orientation are called health disparities. Health disparities are defined by the United States National Institutes of Health as differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions between specific population groups. The NMDOH report Health Status Disparities in New Mexico, published in March 2003, provides a comprehensive look health disparities in the state based on gender, ethnicity, education level, and income. After collecting a decade s worth of data, researchers identified, categorized, and analyzed nearly 40 health indicators. Overall, health disparities in New Mexico were greatest for Native American populations; Hispanics had the poorest perception of health and the highest rates of teen birth, drug-related death, firearm injury death, chlamydia, and binge drinking. They experienced the greatest disparity increases for teen births and hepatitis B, and the greatest disparity decrease for smoking. Education and income were closely related to health disparities. Those with the highest education levels and highest incomes experienced the least disparities. Males experienced higher rates than females for almost every indicator, including all death indicators. Females had higher rates of pertussis (whooping cough), shigellosis, and chlamydia, and a poorer perception of health than males. The greatest decrease in

18 DAC HHS Alliance Action Plan 18 9/6/2006 disparity by gender was seen for motor vehicle injury death, while the greatest increase in disparity by gender was seen for suicide. (NMDOH March 2003) Access to healthcare and the quality of healthcare received is also affected by ethnicity, income level, gender, and other factors. The 2005 National Healthcare Disparities Report focuses on health disparities in access to medical care throughout the United States. The report contains both good and bad news regarding healthcare disparities. The good news: some healthcare disparities are diminishing, while information about disparities is improving. The bad news: healthcare disparities still exist. The bad news for Doña Ana County: healthcare disparities are growing among Hispanics, and among people living below the poverty line. From a healthcare planning perspective, understanding the determinants of health and patterns of healthcare disparities can help to target the causes of Even the best healthcare plan can t change some things for example, the genetic predisposition to diabetes among Hispanics. But other things can be changed, including lifestyle factors, access to care, and environmental factors such as second-hand smoke. About 70 percent of all premature deaths in New Mexico and the United States are caused by individual behaviors and environmental factors two determinants of health that can be affected by interventions. F. Building a Foundation of Prevention How can healthcare planners change the things that can be changed? Focused prevention and education programs are cost-effective ways prevent disease and improve health outcomes at the population level. Childhood immunization programs are one of the most cost effective. However, planners must be aware that not all prevention activities have the same potential cost effectiveness. For instance, a smoking cessation costs, on average, $1000 per year of life gained; medications to control $100,000; surgery for cardiac disease $500,000 per year of life gained. The earlier prevention intervention happen, the greater the efficiency, and the better the health outcomes. In Understanding Health Policy: A Clinical Approach, Thomas Bodenheimer, M.D. and Kevin Grumbach, M.D. of the Department of Family and Community Medicine at the University of California, San Francisco provide a useful framework for understanding disease prevention. According to this model, disease prevention has three components: primary, secondary, and tertiary prevention: Primary prevention, or efforts to avoid a disease or injury before it happens (for instance, childhood immunizations, banning smoking in public places) Secondary prevention, or screening to detect disease processes during early stages and intervention to slow or stop the progress of the disease (for instance, Pap smears to detect cervical cancer, blood cholesterol level checks and blood pressure checks to detect heart disease risk) Tertiary prevention, or efforts to minimize the effects of disease and disability (for instance, the use of home oxygen to allow someone with chronic obstructive

19 DAC HHS Alliance Action Plan 19 9/6/2006 pulmonary disease (COPD) to live as normal a life as possible, or physical therapy to increase strength and balance in someone with muscular dystrophy) Likewise, prevention strategies can occur at three systemic levels: Address social determinants of disease, especially poverty. Income and social status are directly proportional to health status, a correlation that is wellestablished even in countries where universal health care is available. Economic development may have a greater impact on health than targeted public health programs. However, economic development is impossible if a population is in poor health. For an extreme example, consider African countries ravaged by HIV/AIDS, where a large proportion of the population never reaches the age to enter the labor force. Provide public health interventions to reduce overall incidence of illness. Examples include wastewater treatment, banning cigarette smoking in public places, health education programs on diabetes, depression, and other prevalent diseases, smoking cessation and substance abuse programs, and sex education programs in schools. In 2002, of the $1.6 trillion that the United States spent on healthcare, 3 percent went to public health activities such as these. Preventive healthcare services performed by providers. These services can include both primary prevention, such as childhood immunizations, patient counseling on smoking cessation or reducing risk of sexually transmitted infections, and secondary prevention, such as cancer screening. Recommendations for regular schedules for preventive medical care services have been established by the U.S. Preventive Services Task Force, an independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services. These recommendations can be accessed online at <http://www.ahrq.gov/clinic/uspstfix.htm> At the same time that healthcare planners must recognize that individual behaviors can dramatically affect health, they must also avoid blaming individuals for poor health. As the World Health Organization states, blaming individuals for having poor health or crediting them for good health is inappropriate. Whether a person's health is poor or good is largely situational. Even behavioral factors that could be directly controlled, such as cigarette smoking, driving while intoxicated, and accessing prenatal care, are often determined by cultural norms and expectations. For those who live in poverty, dangerous neighborhoods, and have little motivation for, there may be little motivation to change behaviors. In this case, environmental factors most notably socio-economic ones contribute to behavioral factors, creating a snowball effect. Prevention strategies must address the entire community. Secondary prevention activities such as providing Pap smears to detect cervical cancer are useless if follow-up services are not available. There is an ethical and practical imperative to provide services such as radiation and chemotherapy treatment to those who screen positive to cancer, as well as appropriate follow-up care and education for

20 DAC HHS Alliance Action Plan 20 9/6/2006 those who test positive for diabetes mellitus or others conditions such as hypertension or high cholesterol levels. Prevention and health education activities provide the foundation for an integrated healthcare system that provides access to all services. Adequate, effective, and culturallyresponsive primary, secondary, and tertiary prevention services can avert disease, detect chronic diseases at early, treatable stages, and reduce the cost of end-of-life care. It is predicted that in the long-term, prevention and education activities reduce the need for more expensive specialized services, ensuring that those services will be available to those who need them. G. Healthy Gente 2010: A Framework for Action Healthy Gente is a health promotion and disease prevention agenda that draws on the national health indicators defined in Healthy People Healthy Gente 2010 indicators are a set of health status indicators developed for U.S. communities that border Mexico. It identifies 25 of the most important preventive health goals, indicators, and strategies, resulting in a strategic management tool that can be used by the four US border states, communities, and other public and private sector partners. The goals of Healthy Gente 2010 are to increase quality and years of healthy life and eliminate health disparities. Healthy Gente grew out of preparatory work for the U.S.-Mexico Border Health commission s Healthy Border 2010 agenda. The US-Mexico Border health Commission serves as a forum for addressing critical health issues in the border region. Healthy Gente indicators were developed by members of the Design Team, the support group for the Border Health Commission, including the directors of the four U.S. state border health offices. The team used four principles to guide the selection of indicators: 1) they should address key health issues on the border; 2) they should be limited in number; 3) to the extent possible, the objectives should be measurable; and 4) they should be compatible with federal and state indicators. The goal was to develop a set of indicators that will resonate with the border population will be easily understood, and will help to coordinate further public and private health programs. The Healthy Gente indicators are not objectives, but a framework for each responsible county, municipality, or region to develop its own objectives based on current status, available resources, and time available. The 25 indicators cover the majority of the focus areas identified by Healthy People The indicators, grouped according to topic, are: Access to Care Reduce by 25% the population lacking access to primary care Cancer Reduce female breast cancer death rate by 20% (per 100,000 women) Reduce cervical cancer death rate by 30% (per 100,000 women)

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